Awful situation currently

Flugelhorn

V true - have had to admit patient from care homes / nursing home etc to hospital and have to make sure that the ambulance crew have sight of the DNAR before they leave as if the person arrests en route then they are obliged to resuscitate.

NOK (or appropriate people anyway) do come into play if the hospital medical staff have to make a "best interests" decision. DNAR forms have a section on them where the decision is made "in the best interests of the patient" - then reasons why it was not possible to discuss it with the patient and then the names / dates / times / relationship of the peopel it WAS discussed with.
Recently had this for close relative - consultant asked me "is there anyone else we need to discuss this with"

Margot123

I know we are going slightly off-topic but the issues of NOK and DNAR are in dire straights.

Like others have said, the hospital staff only want someone (anyone) to accept the role of NOK; I can only imagine this is due to bed-blocking etc. A 'needs must' approach.

When an elderly relative was admitted in a terrible state, I was well-aware that their wishes were for an attempt to be made at resuscitation, as they had spoken recently about it (and wanted to live despite being frail and over 95).
When the relative was unable to speak, the Dr said directly to me 'there is a DNAR in place'. I was shocked to hear this and challenged him to produce it. Obviously, no one could, as no DNAR existed.
I was livid, as had I not been a self-appointed NOK, the Dr would have left this relative to die against their wishes.
FYI the relative 'pulled through' and lived nearly another 4 years; just passing before their 100th Birthday. They were in fairly good health and passed in their sleep.

Flugelhorn

one of the reasons that can be indicated on a DNAR form is that it is "unlikely to be successful" ie the patient is likely to be approaching a natural death, at which no amount of CPR / defib / drugs will make a difference.
Really only good chance of success when the person is younger, the incident is sudden and the heart / lungs are relatively healthy.

It is crucial that we all have the discussions with our nearest and dearest and make sure our wishes are recorded. What is difficult though is realising when you are at the age that you should start thinking about these things ....

I recently saw a DNAR form for the south west region and felt it was very well thought out - there was the usual DNAR bit but also discussions about admission and in what circumstances, oral antibiotics v. iv antibiotics etc, use of drips etc..


Deciding right is a good site to get some info
http://www.necn.nhs.uk/wp-content/uploads/2015/05/210515-Deciding-Right-Patient-FAQs-FINAL.pdf

Margot123

"one of the reasons that can be indicated on a DNAR form is that it is "unlikely to be successful" ie the patient is likely to be approaching a natural death.........."

Yet this presents another problem of generalisation. Again, this is subjective. The example I gave of my elderly relative may be an exception to the rule but it does happen.

I can only assume that DNARs are a cost-saving exercise in the guise of 'doing what's right for the patient'. I'm not saying life should be prolonged at all costs; I have very strong beliefs on what is the correct thing to do.
However, when an individual has stated categorically that they want to be resuscitated, then attempts should be made.

Yorkshireman99

Margot123 wrote: »

"one of the reasons that can be indicated on a DNAR form is that it is "unlikely to be successful" ie the patient is likely to be approaching a natural death.........."

Yet this presents another problem of generalisation. Again, this is subjective. The example I gave of my elderly relative may be an exception to the rule but it does happen.

I can only assume that DNARs are a cost-saving exercise in the guise of 'doing what's right for the patient'. I'm not saying life should be prolonged at all costs; I have very strong beliefs on what is the correct thing to do.
However, when an individual has stated categorically that they want to be resuscitated, then attempts should be made.

I attended another local NHS hospital last week. I live equidistant between two but it was more convenient on this occasion. I as shocked, and appalled, pardon the pun, to see prominent signs at the entrance stating that resuscitation was the default policy. Upon enquiring I was told that this was regardless of the patient.s age, health or likelihood of success unless a DNR was in place. I shall be pursuing this as it contrary to what I understand to be good clinical practice. Comments welcome and apologies to the OP for the thread drift.

Red-Squirrel_2

Margot123 wrote: »

"one of the reasons that can be indicated on a DNAR form is that it is "unlikely to be successful" ie the patient is likely to be approaching a natural death.........."

Yet this presents another problem of generalisation. Again, this is subjective. The example I gave of my elderly relative may be an exception to the rule but it does happen.

I can only assume that DNARs are a cost-saving exercise in the guise of 'doing what's right for the patient'. I'm not saying life should be prolonged at all costs; I have very strong beliefs on what is the correct thing to do.
However, when an individual has stated categorically that they want to be resuscitated, then attempts should be made.

This is shockingly ignorant.

Are you aware of the success rates of CPR?

elsien

If a DNAR is considered to be futile - i.e. it will not restart the heart - then it is a clear clinical decision and the person/their representatives should be informed of this. Informed, not consulted.

If CPR would restart the heart but the DNAR is being considered on the balance of benefits and burdens then the person should be consulted. It being distressing is not a valid reason not to consult unless the person has clearly said "don't tell me, I don't want to know" or it can otherwise be justified. If the person has capacity, then it is their wishes that should be taken into account.

If the person lacks capacity around the decision then if practicable, their wishes and views should still be ascertained. It should be clearly evidenced why this has not been done, if the decision is made not to involve them. If there is no power of attorney in place then if there are friend/family they should be consulted. Please note, this can be any family/friends who are involved and who the person wishes to speak for them, not necessarily whoever has managed to get themselves designated as next of kin. If the person has no-one willing and appropriate to consult then an IMCA (mental capacity advocate) should be involved. A best interest's decision is made by the senior clinician involved in the person's care at that time.

And as with any medical treatment, power of attorney or not, you can't insist on something that all the clinicians agree is a very bad idea. Although a second opinon can be requested if the person/their representatives disagree.

And the number of DNARs ignoring the above guidance that I have seen and where no-one has been consulted, least of all the patient, far outweigh those completely correctly and in accordance with the law and GMC guidelines.

However, for those who don't know the figures, in hospital onlyabout 2 out of 10 people survive long enought to leave hospital. The figues are lower for people with serious underlying conditions and for people where CPR was attempted outside of the hospital setting. It's not like on Casualty, it's very painful and with many people if they do survive it leaves them in a far worse state afterwards.
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YoungBlueEyes

I'm not sure if this is a regional thing that changes from one county to the next, but where I live resuscitation is always attempted unless an official DNR is produced.

My father had (I believe - we don't know for sure as he donated his body so science to no PM) a small heart attack at 0415, and whilst I was on the phone to 999 he died on me. The first responders that came a few minutes later tried to revive him as it is "standard procedure", even though I'd told them repeatedly he did NOT want it.

I can attest it was a most cruel and brutal procedure. The sound of dad's ribs and other bones breaking was horrific. I only hope he was truly dead by this time, I'd hate to think he was still even partially conscious whilst it was all happening. I don't think I'll ever forget the way he folded in half when the guys from the funeral home lifted him on to their stretcher, the bones crunching again. It was definitely more than a couple of broken ribs.

The whole thing was a true nightmare. The paramedic was sat at my dining table, filling in paperwork, sighing pointedly. I'm sat on the floor, sobbing, with dad laid next to me, and my dog sniffing dad's head. The paramedic said - "I don't know what you're crying so hard for, he was an old man so you must have expected this to happen." I told him he was a disgusting animal and he should be ashamed that my dog was showing more compassion than he was, and told him to leave.

What I really really wish I'd done was get up and punch him in the face. I'm sure there'd be some leniency given the circumstances...

Red-Squirrel_2

YoungBlueEyes wrote: »

The paramedic was sat at my dining table, filling in paperwork, sighing pointedly. I'm sat on the floor, sobbing, with dad laid next to me, and my dog sniffing dad's head. The paramedic said - "I don't know what you're crying so hard for, he was an old man so you must have expected this to happen." I told him he was a disgusting animal and he should be ashamed that my dog was showing more compassion than he was, and told him to leave.

What I really really wish I'd done was get up and punch him in the face. I'm sure there'd be some leniency given the circumstances...

That sounds very very surprising. Did you make a formal complaint?

Flugelhorn

YoungBlueEyes wrote: »

I'm not sure if this is a regional thing that changes from one county to the next, but where I live resuscitation is always attempted unless an official DNR is produced.

..

YBE - I am so sorry to hear your story must have been very traumatic.
Have to say I have attended with paramedics when deaths have occurred and found them very sympathetic, kind and supportive, - so sad that this happened in your case